Background:Contextualizing care is the process of adapting care plans to patients' individual needs and circumstances. For instance, a plan to address poorly controlled diabetes is contextualized when it addresses possible barriers to self-care, such as visual problems that create physical barriers to medication self-administration, or competing responsibilities that interfere with scheduled appointments. Conversely, a failure to attend to contextual factors, such as increasing the dosage of insulin rather than addressing the obstacles to adherence when present, is termed a ?contextual error? because it is an inappropriate plan of care that can lead to clinical deterioration and greater health care cost. Identifying contextual errors requires listening to an audio recording of the encounter and coding the audio for specific indicators of context and clinicians' attention to them. Evidence indicates that inattention to patient context is common, adversely impacts health care outcomes, increases costs through overuse and misuse of services, and creates obstacles to patient adherence to care plans. An extensive program of research on contextual errors and how to prevent them has culminated in a VISN 12 funded quality improvement initiative that is based on audit and feedback, in which audio recorded data is collected by Veterans on provider attention to care planning, analyzed and organized using Content Coding for Contextualization of Care (?4C?) system and fed back to PACTs and clinicians to facilitate continuous quality improvement. Objectives: To identify the most efficient, effective, and acceptable data driven strategy for improving contextualization of care in VHA through an implementation and efficacy study of the expansion of an audit & feedback for contextualizing care intervention package (?package?) in VISN 12. The study will assess the efficacy of the intervention package at two levels of intensity, the effectiveness of implementation strategies, and the potential of the intervention to pay for itself by reducing unnecessary care. Design: We propose an Effectiveness-Implementation type 2 hybrid design because we have two co-primary aims: optimizing implementation and evaluating the intervention's effectiveness. In addition, we seek to document the costs and cost savings of the intervention package to ascertain its budget impact. The project will utilize the RE-AIM implementation-evaluation framework to assess the reach, effectiveness, adoption, implementation and maintenance of the intervention. The project will add four additional sites to the two currently engaged in the package, two in VISN 12 and two outside. The rollout of the package will follow a randomized stepped wedge design comparing baseline at the 4 new sites (no intervention) to both a standard and enhanced feedback intervention, with the latter more intensive but more costly. Analysis: Assessment of efficacy will measure impact on contextualization of care rates, health care outcomes, and costs, the latter through a budget impact analysis. Assessment of implementation will employ survey and focus group methods to identify and address obstacles to implementation, optimizing the extent to which it is perceived as safe, not burdensome, and valuable by clinicians and patients. Impact: This project takes a decade of research on contextual error and a recent pilot project to prevent them, and applies that work to the refinement and assessment of a strategy for reducing these errors with an approach that may be scalable and transformative for the Veterans' care. By focusing on ?novel strategies to change provider behavior within the context of a learning health care system,? it is a response to the Provider Behavior RFA. It is also aligned with the VHA's new Blueprint for Excellence which seeks, through ?performance improvement?to improve not only the care, but the health and well- being of individuals.?

Public Health Relevance

Excellent care is not only based on the most up to date and scientifically rigorous evidence, but is also tailored to the individual needs of Veterans. For instance a care plan for a particular patient with diabetes may include the most appropriate medications but it will not be successful if it does not also take into account challenges the Veteran faces in taking those medications, such as night shift responsibilities that conflict with the dosing schedule. This project assesses and expands a pilot program in which patients volunteer to audio record their encounters for the purpose of collecting information to improve their care teams' attention to their individual needs and circumstances, or context. The audio recordings are listened to by trained VA staff who identify opportunities for doctors and other VA care providers to improve their attention to each Veterans' personal needs when planning their care. The information serves as feedback to help the care team better customize care.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Health Care System Organization and Delivery (HS5A)
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Jesse Brown VA Medical Center
United States
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